Nigel Hammond
9 Oct 2024 · Coroner Nigel Parsley · Suffolk
This report repeats 3 earlier warnings. See the linked reports.
The coroner's concerns
1. lack of direct referral to crisis team
“I am concerned, as had the AHMP in [the deceased]'s case been able to directly refer him to the Crisis Resolution and Home Treatment Team on the 9th March 2024, mental health professionals would have attended, and been able to provide additional support, advice and potentially additional treatment for [the deceased], in all likelihood preventing his death.”
Linked reports
Closely relatedConfidence 0.90 · high
Earlier report
“GPs are unable to refer patients (including patients recently having involvement with mental health services) directly to Mental Health Service without first undertaking a physical health check, thereby causing delay”
This report
“an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Closely relatedConfidence 0.85 · high
Earlier report
“On 25 February 2016 Mr [name redacted] was referred by a Social Worker at Herring House, where he was residing, to the Community Mental Health Team and he was given an appointment for 21 March 2016, under 4 weeks from the date of the initial referral.”
This report
“However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”
Closely relatedConfidence 0.80 · moderate
Earlier report
“The adequacy of NSFT's Crisis Rehabilitation Home Treatment Team (CRHTT) response to an urgent referral, in particular; risk assessment, safety planning and decision making concerning the downgrading of referrals.”
This report
“However, the court was told that an AMHP, despite their role in the coordination of the mental health assessment and admission to hospital of a patient, were not permitted to make direct referrals to the emergency Crisis Resolution and Home Treatment Team.”